University:
West Coast University
Course:
NURS 110 | Introduction to Professional Nursing
Academic year:

2020
Views:

94

Pages:

1
Author:

Accinkiquicpqw

Patient’s Initials: D.O.B.: Concept Care Plan example        Nursing Problem: Risk for secondary infection, acute pain related to the diarrhea, depression brought on by isolation, fall risk due to weakness, bed sores due to not ambulating, output (such as diarrhea) could be more than the input (drinking/IV fluids) due to not taking in enough fluids to meet the output. Collaborative Problems: “I am feeling lonely.” Patient is at risk for depression, so psychiatric care is necessary. Patient is obese, so a dietician would be beneficial to her health. “I feel weak.” Patient should attend physical therapy to regain strength. Nursing Dx: Fluid Volume Deficit o (R/T): Related to active fluid volume loss due to diarrhea from antibiotics as evidence by patient having loose, watery stools and unable to control bowel movements. o (AEB): decreased intake, resulting in output more than input, diarrhea, patient stating “may I have something to drink”, indicating thirst and possible dehydration, tenting, edema Client Outcome: Patient will report less diarrhea within 2 hours after prescribed anti-diarrheal medication. Patient’s intake and output will be equal within 72 hours. Patient will maintain a normal blood pressure, heart rate, and body temperature within 2 to 4 hours. Patient’s skin turgor will be brisk and under 3 seconds within 24 hours. Subjective Data: “May I have something to drink?” “I am feeling weak.” Objective Data: tenting, tachycardia with a heartbeat of 104 bpm, BP 120/80, respirations 22, loose, watery, stools for 2 days, test results showed positive for C. Diff, pallor Nursing Interventions and Rationales: o 1) Nursing intervention and Rationale: Monitor pulse, respiration, and blood pressure of patient every hour until patient is stable, and them monitor the vital signs every 4 hours. (Rationale): A systemic review demonstrated that hypotension and tachycardia, and occasionally fever, are clinical signs of dehydration. (Wagner & Hardin-Pierce, 2014) o 2) Nursing Intervention and Rationale: Keep the patient hydrated with IV solutions ordered from the physician. (Rationale): For clients with mild to moderate fluid deficit, crystalloids such as 0.9 saline or lactated Ringer’s should be used for fluid volume replacement. (Peng & Kellum, 2013; Ackley, Ladwig, & Makic, 2017) o 3) Nursing Intervention and Rationale: Monitor the patient’s urine by noting the color, odor, urine osmolarity, and specific gravity. (Rationale): Normal urine is straw-colored or amber. Dark-colored urine with a specific gravity grater than 1.030 and a high urine osmolality reflects fluid volume deficit. (Wagner & Hardin-Pierce, 2014; Perrier et al, 2014; Ackley, Ladwig, & Makic, 2017)